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EXPLORING THE HIDDEN CURRICULUM: A qualitative analysis of medical students’ reflections on professionalism in surgical clerkship
KITTMER TPEMBERTON JHOOGENES J CAMERON BH
ASE March 22, 2012
MacSERGMcMaster Surgical Education
Research Group
Background I
Clerkship is a unique time in professional development
Professionalism curriculaFormal – Professional Competencies1
Informal – bedside teachingHidden2-4
1Risdon and Baptiste 2006, 2Stern and Papadakis 2006, 3Karnieli-Miller et al 2011, 4Hicks et al 2001
Background II
Reflective writing in clerkship• Effective5
• Implemented in various forms5-8
Qualitative professionalism research has been used to explore the hidden curriculum,7-9 but never with an explicit focus on surgical clerkship
5Hill-Sakurai et al 2008 6Wald and Reis 2010, 7Kaldjian et al 2011, 8Karnieli-Miller 2011, 9Hicks et al 2001
2001 2 3 4 5 6 7 8 9 20100
500
1000
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'Professionalism' on PubMed last decade
Professionalism + medical education+ surgery
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Objectives
To identify and explore the main challenges in ethics and professionalism experienced by medical students during their surgical clerkship at McMaster as recorded in their critical incident reports (CIRs)
To assess for differences between junior and senior clerks’ CIR topics
Methods I• Qualitative approach• Divided CIRs into 2 groups: early and late• 4 reviewers independently identified and then
collaboratively determined emerging themes– Created codebook iteratively– Continued to conceptual saturation– Data reduction
• 2 reviewers re-read CIRs and recorded concept frequencies
• Validation– Data & investigator triangulation, audit trail, member-checking
Methods II
64 reports available from class of 2009
39 early group 25 late group
Results
Clerk
Patient(14)
Team(6)
System(4)
Self(3)
27 themes in total
Clerk-Self
"Frustration, exhaustion, helplessness were only some of the emotions present in the room as we went through a six hour procedure, our last chance to make a difference, but considered by all to be most likely a futile endeavour to save the patient's life."
Stress & emotions Resolving ambiguity Responding to patient suffering
Clerk
Patient
Team
System
Self
Clerk-Patient I Ethical Decision-Making
– Patient Dignity – Patient Confidentiality – Patient-Centred Care – Provider bias – Do Not Resuscitate (DNR) & Code status – End of life issues – Informed consent (decision making) – Substitute Decision-Maker (decision making) – Patient autonomy
Clerk
Patient
Team
System
Self
“Reacting to stressful situations by revealing your frustration can only contribute to the patient's anxiety and possible apprehension, and I believe in this case his humiliation - if I had been in his position, I would have felt like I was burdening the team with my unfortunate problem.”
Clerk-Patient II
Communication– Cultural Competency – Health Literacy – Breaking Bad News– The Difficult Patient – Disclosure of Adverse Event
Clerk
Patient
Team
System
Self
“When the words 'lymph nodes' were spoken, I
saw on the faces of the family members that they did not understand.”
Clerk-Team Clerk-Team
– Team communication – Level of responsibility – Hierarchy– Interprofessional communication– Barriers to learning– Bullying
“[Verbal abuse] also interferes with our ability to learn [...] I have overheard several clerks state that they simply don't want to be in the OR anymore as it isn't worth the abuse.”
Clerk
Patient
Team
System
Self
Clerk-System
Clerk-System– Patient advocacy – Safety – Healthcare resource management – Medical error
“I thought about hospital environment a few days ago. I believe that our patients (especially in surgery) suffer enough from their diseases. They came to us looking for help and relief. And it is our job to make the hospital environment safe for our patients.”
Clerk
Patient
Team
System
Self
Discussion I
Professionalism curriculum well-received• Positive feedback in clerks’ exit surveys
Communication and self-care were most frequent themes• Learned with practice and experience• Not always modeled well
Negative CIRs more common• Assignment wording bias: “challenges”• Previous research suggests assignment wording
influences types of issues students discuss7
7Kaldjian et al 2011
Discussion II
Junior vs. senior clerks:Varying levels of clinical experience &
independenceThose wishing to match to surgery tend to
do core surgery early in clerkshipPossible burnout later in clerkship
Limitations
Conclusions
• CIRs are a rich source of information• Clerks face diverse challenges in their
interactions with self, patients, their team and the healthcare system
• Junior and senior clerks may have different educational needs
• Clerks are sensitive to the examples of professionalism they see every day
Clerk
Patient
Team
System
Self
Future Directions
Addressing the hidden curriculum10-11
Spreading the information to staff surgeons, residents, curriculum planners○ What clerks struggle with most○ What we can do better○ Enhance teaching of CanMEDS competencies
Curriculum development5
New plans for a longitudinal professionalism curriculum in clerkship○ Modeled after surgical rotation ○ CIR/Case + small-group discussion
10Christian et al 2008, 11Busing et al, 5Hill-Sakurai et al 2008
Acknowledgments
Small Group Facilitators Class of 2009 clerks at the Michael G.
DeGroote School of Medicine Funding
• McMaster Surgical Associates• McMaster Pediatric Surgery Research
Collaborative
References• Branch W, Pels RJ, Lawrence RS, Arky R. “Becoming a doctor: Critical-Incident reports from third-year medical
students.” NEJM. Oct 1993: 1130-2.• Busing N et al. “Recommendation V: Address the Hidden Curriculum.” The Future of Medical Education in
Canada: A collective vision for MD education. Associations of Faculties of Medicine of Canada Website, 2010. <http://www.afmc.ca/future-of-medical-education-in-canada/medical-doctor-project/index.php>
• Christian F, Pitt DF, Bond J, Davison P, Gomes A. “Professionalism – connecting the past and the present and a blueprint for the Canadian Association of General Surgeons.” Canadian Journal of Surgery.
• Hafferty FW. “Beyond curriculum reform: confronting medicine's hidden curriculum.” Academic Medicine. 2008;73(4):403-7.
• Hill-Sakurai LE, Lee CA, Schickedanz A, Maa J and Lai CJ. “A professional development course for the clinical clerkships: developing a student-centered curriculum.” J Gen Intern Med 23(7):964-8.
• Kaldjian LC, Rosenbaum, ME,Shinkunas LA, Woodhead JC,Antes LM, Rowat JA,Forman-offman VL. “Through students’ eyes: ethical and professional issues identified by third-year medical students during clerkships.” J Med Ethics 2011.
• Lempp H, Seale C. “The hidden curriculum in undergraduate medical education: qualitative study of medical students' perceptions of teaching.” BMJ. 2004 Oct 2;329(7469):770-3.
• Reisman AB. “Outing the Hidden Curriculum.” The Hastings Center Report. 2006;36(4):9.• Risdon C and Baptiste S. “Evaluating pre-clerkship professionalism in longitudinal small groups.” Medical
Education 2006. 40: 1130-1.• Wald HS and Reis SP. “Beyond the margins: reflective writing and development of reflective capacity in medical
education.” J Gen Intern Med 25(7):746-9.